Management of intramedullary spinal cord tumors: A single-center experience of 247 patients.

Intramedullary spinal cord tumors (ISCT) are rare tumors requiring multidisciplinary care in an expert center. Here, we report a single-center experience including 247 patients with ISCT: 134 ependymomas, 54 astrocytomas and 59 hemangioblastomas. Preoperative evaluation and surgical considerations are discussed to share our principles in managing these patients. Ependymomas are largely benign lesions (95% of WHO grade II) for which total resection (91% rate of gross total resection (GTR)) without neurological impairment (79% of patients remained stable or improved) is the goal in order to ensure long-term oncological control (94.5% overall survival at 5 years, excluding anaplastic ependymomas). On the other hand, astrocytomas are more frequently high-grade tumors (30% of WHO grade III or IV) for which partial resection (60% of cases) is often necessary to preserve neurological status (48% of patients deteriorate at one year), leading to higher rates of recurrence (60% recurrence rate at 5 years for grade III astrocytomas). Lastly, spinal hemangioblastomas require a specific microsurgical resection with particular attention to the vasculature in order to ensure en bloc resection (95% GTR), allowing excellent neurological results (12% of patients improved, 86% remained stable). Altogether, these results demonstrate that ISCT can be managed surgically with good functional outcome, while oncological results will mostly depend on the histopathological grading.

Vasogenic oedema during stereoelectroencephalography: intracranial pattern and late-onset clinical repercussion.

In patients suffering from focal drug-resistant epilepsy, intracranial explorations are the gold standard for identifying the epileptogenic zone and evaluating the possibility of a surgical resection. Amongst them, stereoelectroencephalography (SEEG), using depth electrodes, is a safe procedure. However, complications occur on average in 2% of cases, notably haemorrhages or infections. Vasogenic cerebral oedema constitutes a rarely reported complication. Amongst the 85 patients explored with SEEG between January 2017 and September 2023, three had a clinically and electrophysiologically relevant vasogenic cerebral oedema. In these three patients, the surgical procedure was uneventful. In all three as well, electrodes exploring areas away from the epileptogenic zone recorded some unexpected focal delta slowing with clinically asymptomatic superimposed discharges, a pattern so far only reported in cases of bleeding. Moreover, one patient experienced confusion 10 days after explantation. Post-explantation magnetic resonance imaging showed, in all three patients, a vasogenic oedema that fully resolved a few months later. We did not identify any contributing factors, and there were no particularities concerning the number of electrodes, their implantation site or the recording duration. Focal delta slowing and rhythmic discharges during SEEG can indicate a vasogenic oedema. Clinical consequences can occur after explantation. Evolution is favourable but this misleading pattern must be identified.

Prognostic factors for unfavorable outcome after mild traumatic brain injury. A review of literature.

BACKGROUND: Unfavorable outcomes occur in 15-20% of patients with mild traumatic brain injury (mTBI). Early identification of patients at risk of unfavorable outcome is crucial for suitable management to be initiated, increasing the chances of full recovery. Many studies have been published on prognostic factors, but are not of a high level of evidence and certainty. A number of factors have been proposed and predictive models have been constructed that, although attractive, have not yet been externally validated. OBJECTIVES: A review of literature (systematic search of PubMed and Google Scholar) assembled relevant available information about prognostic factors for unfavorable outcome after mTBI. We discuss the consistency of these findings, and the possibility and difficulty of using these factors in a daily practice. RESULTS: It appears that the strongest and most consistent predictors are the number, severity and duration of symptoms present in the first few days after the trauma.

The relevance of the artery of Adamkiewicz for microsurgical resection of spinal tumors- short overview and case series: Technical note.

INTRODUCTION: There is of major interest to know the exact anatomical location of artery of Adamkiewicz (AKA) for many spinal microsurgical procedures, so as to avoid postoperative ischemia of the spinal cord, with further devastating clinical impact. METHODS AND RESULTS: We detail the interest of preoperative angiography for medullary lesions in our experience. We further report two cases where the AKA was located at the same level and side with the treated lesion. The first case underwent an intracapsular decompression. The second patient undertook radiosurgery by Cyberknife. CONCLUSION: For spinal tumor where the AKA is exactly on the same level and side, an intracapsular decompression can be safely performed, with an immediate decrease of the symptomatic mass effect, while decreasing the risk of neurological injury. A second valuable alternative in such situations can also be radiosurgery, for small to medium size tumors. In our experience, this proved safe and effective both for tumor and eventual pain control.

A rare condition: Spontaneous subarachnoid haemorrhage due to spinal hemangioblastoma: Report of 2 cases and review of the literature.

INTRODUCTION: Subarachnoid haemorrhage (SAH), secondary to spinal hemangioblastoma (HBL), is extremely rare, with only a few case reports to date. We report the experience of our reference centre for spinal tumours and Von Hippel-Lindau (VHL) disease in patients with spinal HBL presenting with SAH. We further performed a systematic review of the literature. METHODS: We report two cases. A systematic search was performed using the PubMed, Embase and Cochrane databases, with no limit for publication date. Inclusion criteria were: patients with HBL presenting with SAH, with or without VHL. The systematic review retrieved only 10 studies, including 16 patients. RESULTS: In our centre, the first case concerned radicular HBL at D12 level, presenting with spinal and brain SAH. The patient underwent uneventful microsurgical en bloc resection. Postoperative course was normal. The second case concerned HBL with SAH at the cervico-medullary junction, with rapidly fatal course. The systematic review revealed female predominance, at a median age of 40 years, with HBL predominantly located at cervical level, common preoperative symptoms being headache and signs of meningeal irritation. CONCLUSIONS: In conclusion, spinal HBL is an extremely rare cause of SAH. The systematic review found putative risk factors: female gender, age 40-50 years, cervical location, and median size 2cm. Diagnosis can be difficult when presentation mimics intracerebral SAH. We advocate early surgical removal. The risk of rapidly fatal course, in case of major haemorrhage, needs to be borne in mind.

[Intramedullary ependymomas: A French retrospective multicenter study of 221 cases]. / Épendymomes intramédullaires : étude rétrospective multicentrique française sur 221 cas.

AIM: Intramedullary ependymomas (IE) are the most frequent intramedullary tumors in the adult population. The gold standard treatment is to obtain gross total removal without any new postoperative neurological deficit. The authors report the results of a multicenter series with a long-term follow-up and the analysis of clinical, radiological, surgical data as well as the complementary treatments. MATERIALS AND METHODS: A retrospective analysis of adult patients with IE operated on between January 1984 and December 2011 at 7 French centers (Bordeaux, Kremlin-Bicêtre, Lille, Lyon, Marseille, Montpellier, Nice, and Nîmes) was performed. The minimal follow-up was 12 months. The clinical evaluation was based on the McCormick classification in the pre and postoperative period at 3 months, 1 and 5 years. RESULTS: Data of 221 adult patients with a pathologically confirmed diagnosis of IE were considered: 134 patients were treated at the Neurosurgical Department of Kremlin-Bicêtre Hospital, 26 were treated at Lille and 61 were treated in the southern region of France (Marseille, Bordeaux, Montpellier, and Lyon). The epidemiological analysis was performed on the entire cohort of patients, while follow-up considerations were made solely on the 134 patients managed at Kremlin-Bicêtre Hospital to obtain homogeneous data. A slight male prevalence was observed (59 % of cases), with an average age of 41.8 years at diagnosis. The mean age at first clinical manifestations was 39.6 years, thus the average duration of symptoms before the diagnosis was 29 months. Neuropathic pain and neurological deficit were the most revealing symptoms in 64 % and 32 % of cases respectively. The localization of the IE was basically cervical in 35.7 %, primarily thoracic in 25.8 % and cervico-thoracic in 22.2 %. The mean tumor length in the sagittal plan was 20.4mm (range 1 to 99mm). A cystic cavity was present in 76.5 % of cases while an intratumoral hemorrhage was detected in 30.3 % of cases. The rate of complete removal was performed in 79.2 % of cases when considering the whole cohort and in 91 % of cases treated at Bicêtre Hospital. In 95 % of cases a WHO grade I or II ependymoma was isolated and in 5 % of cases a WHO grade III. The McCormick scale (MCs) (Lou et al., 2012) [1] was used to rate the degree of preoperative functional impairment in 4 grades. In the immediate postoperative period a worsening of functional capacity was observed. Only 28.8 % of patients had MCs 1 in the immediate postoperative period; 34.8 % had MCs 2; 20.4 % had MCs 3 and 16 % had MCs 4. At 5 years of follow-up (101 patients) the frequencies of grades 1 and 2 were increased: 59 % of patients had MCs 1, 20.8 % had MCs 2, 10,9 % had MCs 3 and 9.3 % had MCs 4. The extension of the lesion on the sagittal plan calculated on the preoperative MRI, was the only predictive factor associated with the immediate postoperative outcome and the short-term follow-up (P=0.04), whereas the preoperative neurological status is the only predictive factor for long-term follow-up (P=0.005). CONCLUSION: Gross total removal remains the mainstay treatment for IE. Early surgery is indicated if the patient is symptomatic or the tumor increases in size. A postoperative regular follow-up is mandatory for at least 10 years due to the risk of recurrence. If a growing residue is detected, a second intervention is recommended without any adjuvant treatment if a WHO grade I lesion is confirmed by the pathological analysis. Complementary treatment should be reserved for high-grade ependymomas or in case of unresectable and progressive residue.

[Intramedullary hemangioblastomas]. / Les hémangioblastomes intramédullaires.

AIM AND BACKGROUND: Intramedullary hemangioblastomas are rare lesions representing 1 to 5% of spinal tumors. The aim of this study was to review our experience with the surgical management of intramedullary hemangioblastomas. MATERIALS AND METHODS: We performed a retrospective analysis of all the patients with intramedullary hemangioblastomas operated on between 1993 and 2011 in our department. All the patients were screened for Von Hippel Lindau disease. The minimum follow-up was 3 years. The clinical presentation, radiological findings, surgical procedure and outcomes were recorded and analyzed. RESULTS: Our consecutive series included 59 patients with a total of 65 tumors. The mean age at diagnosis was 38 years. Forty-two patients (72.5%) had Von Hippel Lindau disease. The main symptom was pain (58% of cases). The most common location was cervical spinal cord. The average size was 15mm. The resection was complete in 95% cases resulting in clinical improvement in 12% cases, stability in more than 86% of cases and deterioration in less than 2% cases. CONCLUSION: All patients with intramedullary hemangioblastoma should have a screening for the Von Hippel Lindau disease and if the diagnosis is correct, close monitoring should be initiated. Surgical removal is strongly advised in cases of neurological deficits or radiological progression of the tumour.

[Intramedullary astrocytomas: A French retrospective multicenter study]. / Astrocytomes intramédullaires : analyse rétrospective française multicentrique.

AIM: The authors report the results of a multicenter retrospective series with a long-term follow-up and the analysis of clinical, radiological, surgical data as well as the complementary treatments in patients with intramedullary astrocytomas (IA). MATERIALS AND METHODS: We performed a retrospective analysis of all the patients with IA operated on between 1984 and 2011 at 7 French centers (Kremlin-Bicêtre, Lille, Lyon, Marseille, Montpellier, Nice, and Nîmes). The minimum follow-up was 12 months. The clinical evaluation was based on the McCormick scale (MCS) results from the pre- and postoperative period. RESULTS: Data from 95 patients with a pathologically confirmed diagnosis of IA were considered: 54 patients were treated at the Neurosurgical Department of Kremlin-Bicêtre Hospital, 8 were treated at Lille and 33 were treated in the south region of France. The epidemiological analysis was performed on the whole cohort of patients while follow-up considerations were made solely on the 54 patients managed at Kremlin-Bicêtre Hospital to obtain homogeneous data. The average age at diagnosis was 35.6 years without significant gender difference (47 % men for 53 % women). The age at first clinical manifestation was 33.7 years. The average duration of the symptoms before the diagnosis was 22.9 months. Neuropathic pain was the principal revealing symptom (76 % of cases). The localization of IA was thoracic in 40 %, purely cervical in 28.4 %. Complete removal was achieved in 29.5 % of cases when considering the whole cohort and in 38 % of cases treated at Bicêtre Hospital. The histological distribution recorded was: grade 1 in 35 %; grade 2 in 35 %; grade 3 in 22 % and grade 4 in 8 %. During the early postoperative period (3 months) a worsening of functional capacity was observed with an increase in the frequencies of ranks 3 and 4 of MCS in 18.4 %. At 5 years follow-up, the frequencies of ranks 1 and 2 were increased. The application of a Cox model for the determination of the relative risk of death for IA grade 1 and 2 (66 patients) showed a probability of survival at 5 years of 78.6 % (CI 95 %: 68.6 %-87.6 %). Survival at 10 years is to 76.8 % (CI 95 %: 62.3 %-84.2 %). CONCLUSION: Surgery is indicated if the patient is symptomatic or the tumor increases in size. A radical excision remains the mainstay of treatment, while searching to preserve the motor function. A total resection was however only possible in 38 % of cases. A regular postoperative follow-up is compulsory and the adjuvant treatment is based on chemotherapy and radiotherapy according to the histological type.

[Adult intramedullary gliomas]. / Tumeurs gliales intramédullaires de l'adulte : la série du rapport.

OBJECTIVES: Intramedullary gliomas are rare tumors accounting for less than 4% of all primary central nervous system tumors. The aims of this retrospective multicenter study were to assess their natural outcome as well as management. METHODS AND MATERIALS: We studied 332 patients from 1984 to 2011. Histopathological examination revealed 72% ependymomas (94% were low grade tumors), 24% astrocytomas (29% were high grade tumors), 2.4% mixed gliomas and 1.7% oligodendrogliomas. RESULTS: The mean age at diagnosis was 42.4 years for ependymomas, with male predominance, versus 39.6 years for astrocytomas. Pain was the most common initial presentation. In 20% of cases, astrocytomas were biopsied alone, but more than 80% of ependymomas had surgical resection. Radiotherapy and chemotherapy were reserved for malignant tumors, especially if they were ependymomas. The 5-year survival rate was 76.8% for astrocytomas and 94.5% for ependymomas. Histology, functional status prior to surgery, and tumor grade are among the prognostic factors. CONCLUSION: Our study showed that surgical treatment of gliomas is well codified, at least for ependymomas, but adjuvant treatment continues to play a marginal role in the management even in astrocytomas, which are infiltrative tumors.

[Von Hippel-Lindau disease: recent advances in genetics and clinical management]. / Maladie de von Hippel-Lindau: progrès génétiques et cliniques récents.

Von Hippel-Lindau (VHL) disease is a hereditary cancer syndrome that predisposes to the development of a panel of highly vascularized tumors including CNS and retinal hemangioblastomas, endolymphatic sac tumors, clear-cell renal cell carcinomas (RCC), pheochromocytomas and pancreatic neuroendocrine tumors. CNS hemangioblastomas and RCC are the two main life-threatening manifestations. The disease is caused by germline mutations in the VHL tumor-suppressor gene that plays a major role in regulating the oxygen-sensing pathway by targeting the hypoxia-inducible factor HIF for degradation in proteasome. Somatic inactivation of the VHL gene occurs also in most sporadic RCC and sporadic CNS hemangioblastomas. The demonstration of the critical role of VHL in angiogenesis is paving the way for the development of new specific drugs that could represent an attractive potential treatment for VHL but also for sporadic RCC and other cancers.

[Temporary vessel occlusion]. / Clampage vasculaire temporaire.

UNLABELLED: In many situations, temporary artery occlusion is an integral component of aneurysm surgery. The use of temporary clip may allow safer and easier aneurysmal dissection and clipping. Several points, concerning the duration and overall risks of temporary occlusion and the method of choice for cerebral function monitoring have to be discussed. MATERIAL AND METHODS: Non exhaustive review of neurosurgical literature. DISCUSSION: Temporary clip application decreases the risk of intraoperative aneurysmal rupture. The analysis of data published in the literature showed that several questions remain open concerning the optimal method of neuroprotection and cerebral function monitoring, as well as the limit of occlusion duration. Other clinical trials are needed to assess the efficacy and safety of this technique.

[Endoscope-assisted microsurgery for invasive endo- and suprasellar pituitary macroadenomas: a consecutive retrospective study with 13 patients]. / Endoscopie et traitement chirurgical des macroadénomes hypophysaires endo- et suprasellaires invasifs. Une série consécutive rétrospective de 13 patients.

BACKGROUND AND PURPOSE: Surgery of invasive endo- and suprasellar pituitary macroadenomas remains difficult. The records of 13 consecutive patients who underwent transsphenoidal surgery were analyzed in order to evaluate advantages and limitations of endoscopy for surgery of invasive pituitary macroadenomas. METHODS: A transseptal transsphenoidal intersepto-columellar approach was performed with a nasal 0-degree endoscope. Removal of the macroadenoma was performed under the control of a microscope. When the tumor seemed to be completely removed with microscope, a rigid 30-degree endoscope was inserted in the intrasellar and suprasellar regions in order to detect residual adenoma tissue. These residues were removed when technically possible. RESULTS: No rhinologic complication was noted. In 7 patients, the intra- and suprasellar endoscopic view detected a tumor residue which could be removed in each case. Two cases of cerebrospinal fluid leakage occurred during the complementary tumor resection. Two cases of diabetes insipidus and two of rhinorrhea were reported postoperatively. The analysis of the postoperative MRIs showed a complete removal in 23% of the patients (3/13), 75 to 100% removal in 54% of the patients (7/13), 50 to 75% removal in 8% of the patients (1/13) and 50% removal in 15% of the patients (2/13). More than 75% removal was thus achieved in 77% of the patients (10/13). The mean follow-up was 27.2 months. CONCLUSIONS: Rhinologic morbidity was reduced with the endoscopic endonasal approach. Endoscopy complemented with a microscope offered an optimal view of the intra- and suprasellar regions. Endoscopy also improved tumor resection of the invasive endo- and suprasellar pituitary macroadenomas by visualizing hidden suprasellar tumor residues. However, endoscopy was associated with a higher rate of postoperative rhinorrhea.

Innervation of the caudal denervated ventral roots and their target muscles by the rostral spinal motoneurons after implanting a nerve autograft in spinal cord-injured adult marmosets.

OBJECT: The authors conducted a study to determine the effects of using a nerve autograft (NAG) to promote and guide axonal regrowth from the rostral spinal cord to the caudal lumbar ventral nerve roots to restore hindlimb motor function in adult marmosets after lower thoracic cord injury. METHODS: Nine animals underwent a left-sided hemisection of the spinal cord at T-12 via left-sided T9-L3 hemilaminectomy, with section of all ipsilateral lumbrosacral ventral nerve roots. In the experimental group (five animals), an NAG obtained from the right peroneal nerve was anastomosed with the sectioned and electrophysiologically selected lumbar ventral roots (left L-3 and L-4) controlling the left quadriceps muscle and then implanted into the left ventrolateral T-10 cord. In the control group (four animals), the sectioned/selected lumbar ventral roots were only ligated. After surgery, all marmosets immediately suffered from complete paralysis of their left hindlimb. Five months later, some clinical signs of reinnervation such as tension and resistance began to appear in the paralyzed quadriceps of all experimental animals that received autografts. Nine months postoperatively, three of the five experimental marmosets could maintain their lesioned hindlimb in hip flexion. Muscle action potentials and motor evoked potentials were recorded from the target quadriceps in all experimental marmosets, but these potentials were absent in the control animals. Horseradish peroxidase retrograde labeling from the distal sectioned/reconnected lumbar ventral roots traced 234+/-178 labeled neurons in the ipsilateral T8-10 ventral horn, mainly close to the NAG tip. Histological analysis showed numerous regenerating axons in this denervated/reconnected nerve root pathway, as well as newly formed motor endplates in the denervated/reinnervated quadriceps. No axonal regeneration was detected in the control animals. CONCLUSIONS: These data indicate that the rostral spinal neurons can regrow into the caudal ventral roots through an NAG, thereby innervating the target muscle in adult marmosets after spinal cord injury.

[Syringomyelia and Chiari abnormality in the adult. Analysis of the results of a cooperative series of 285 cases]. / Syringomyélie et anomalie de Chiari chez l'adulte. Analyse et résultats de la série coopérative de 285 cas.

This chapter discusses the retrospective data found in 285 patients with syringomyelia associated with Chiari abnormality and collected from 18 neurosurgical departments. A pre and postoperative MRI study and a minimum follow up of at least 2 years were required. A scale of severity was fixed and tested before and after treatment. The size of the cyst, the degree of the foraminal obstruction were analyzed. The mean age at diagnosis was about 39 years and the duration of symptoms about 6.7 years. Sensory disorders were present in 91% of cases, pain in 66% and motor deficit in about 60%. According to our functional classification, the majority of our patients were moderately disabled and only 10.8% showed a severe impotence. Results of the two major surgical procedures, foramen magnum decompression (FMD) (88% of cases) and cyst shunting procedures (SP) (32% of cases) were evaluated with a mean follow-up period of 6.7 years (ranged from 2 to 14 years). Better clinical and morphological results (87% of stabilization or improvement for FMD versus 71% for SP) were obtained by FMD procedure comparing to SP, with the same rate of complications.

[Non-traumatic arachnoiditis and syringomyelia. A series of 32 cases]. / Arachnoïdite non traumatique et syringomyélie. A propos d'une série de 32 cas.

We conducted a retrospective study of 32 patients treated for syringomyelia associated with non-traumatic arachnoid scarring. We selected the cases with documented history of arachnoiditis with pre and post-operative clinical evaluation of the neurological status and anatomical study on MRI with a minimal follow-up of one year. Extensive arachnoid scarring (Group I) was noted in 18 cases, after spinal meningitis in 15 cases (tuberculosis in 9 cases, listeria in 3 cases, pyogenic meningitis in 3 cases), subarachnoid hemorrhage in 3 cases. Focal arachnoid scarring (Group II) occurred in 10 cases, related to spinal surgery in 5 cases (meningiomas: 2, neurinomas: 2, thoracic discectomy: 1), to peridural anesthesia in 1 case, thoracic disc herniation in 1 case, Pott's disease in 1 case, no obvious cause in 2 cases. Basal arachnoid scarring without hindbrain herniation (Group III) was associated with birth injuries in 4 cases. Shunting of the syrinx to the subarachnoid or peritoneal cavity was associated with a recurrence rate of 60% whereas microsurgical dissection of the arachnoid scar and decompression of the subarachnoid space with a recurrence rate of 33%, with a mean follow-up period of 28 months. Successful long-term management of the syrinx was associated with basal or focal spinal arachnoid scarring, no history of spinal meningitis, microsurgical dissection of the arachnoid scar and decompression of the subarachnoid space.

[Secondary intraspinal localizations of glioblastoma. Apropos of a case]. / Localisations secondaires intra-rachidiennes des glioblastomes. A propos d'un cas.

Metastasis of intracranial glioblastomas have been described for the first time more than fifty years ago. They are exceptional and seem to develop clinically in less than 2% of cases. In fact, microscopic metastasis (necropsic series) of such glioblastomas are much more frequent: from 6% for supratentorial glioblastomas to 60% in infratentorial ones; but patients usually die before clinical symptoms appear. The authors report on an intraspinal metastasis which appeared clinically four years after the removal of a frontal glioblastoma. The metastasis was subdural, T3. Preoperative radiological data (CT-scan, MRI) evoked a meningioma, while surgical findings favoured the diagnosis of neurinoma. The diagnosis of glioblastoma metastasis was suggested by intra-operative pathological findings, and confirmed a few days later on smears and stains studies.

[Isolated intramedullary cysticercosis. Case report]. / Cysticercose intramédullaire isolée. A propos d'un cas.

BACKGROUND AND PURPOSE: Cysticercosis is the most common parasitic disease affecting the central nervous system. Although it is still very rare in Europe, the frequency will increase due to the influx of immigrants from the endemic areas and increasing trips in these countries. Spinal intramedullary cysticercosis is an uncommon manifestation of neurocysticercosis. CLINICAL PRESENTATION: We report a case of pure intramedullary cysticercosis in a young white French girl, presenting as a progressive paraplegia with a cystic lesion in T4 on MRI. The diagnosis was made only after surgery by pathological examination. CONCLUSIONS: A preoperative diagnosis of spinal intramedullary cysticercosis must be suspected not only in an endemic area in the presence of multiple soft tissue calcifications and segmental lesions revealed by myelography or MRI studies, but also for all cystic lesion of central nervous system even in no endemic area. Surgery is the unique treatment which can be used for spinal intramedullary cysticercosis and with the use of the microsurgical techniques for medullar surgery the outcome is not as dismal as reported earlier.

[Nocardia farcinica brain abscess: clinical and specific radiological findings and management. Report of two cases in immunononcompromised patients]. / Abcès cérébraux à nocardia farcinica: spécificités cliniques, radiologiques et thérapeutiques. A propos de deux cas chez des patients immunocompétents.

Nocardia spp. cerebral abscesses are rare and usually occur in immunocompromised patients. We report two recent cases of cerebral abscesses due to Nocardia farcinica in immunocompetent patients and review the literature about diagnosis and therapeutic issues. Outcome was good for the two patients following an early identification of the bacteria. Stereotactic biopsy was performed in one case and craniotomy with excision of the abscess in the other case. In both cases, complete identification of the bacteria could be achieved, followed by prolonged antibiotic therapy. Exposure to the germ (mainly telluric) is often difficult to suspect from the past medical history of the patient. Diagnosis is also unexpected. Despite the typically and characteristic aspect on CT and MRI, specific identification and anti-microbial sensitivity profiles are necessary to optimize treatment. In some rare cases, unusual species like Nocardia farcinica, can be resistant to numerous antibiotics requiring adjustments of medical management. Early identification of the bacteria is necessary to achieve good outcome in immunocompetents patients.